Method for Entering, Recording, Distributing and Reporting Data

ABSTRACT

An improved method for efficiently and accurately entering detailed data by yes/no entries so that the data is automatically recorded, optionally automatically distributed and optionally transformed into a readable prose report of the data, which is entered by yes/no markings.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.09/927,972, filed Aug. 10, 2001 and entitled, “METHOD FOR ENTERING,RECORDING, DISTRIBUTING AND REPORTING DATA,” the disclosure of which isincorporated by reference herein in its entirety.

TECHNICAL FIELD

This invention relates to an improved method for efficiently andaccurately entering detailed data by yes/no markings so that the data isautomatically recorded, optionally automatically distributed andoptionally transformed into a readable prose report of the data.

BACKGROUND

Many computer systems have been proposed for entering data of a varietyof types for a variety of purposes. Many of the systems rely uponrelatively standardized yes/no entries but produce relativelynon-informative reports. For instance, in FIG. 1 a prior art system isshown. Particularly when relatively detailed data is being taken andreported, the relatively simplified reporting system in FIG. 1 is whollyinadequate. Among the deficiencies in this type of data record is thefeet that the recorder must expend a certain amount of effort to scanthe yes/no columns for categories for marks and then correlate those tohis findings. The recorders typically object to these seemly trivialefforts which are required to enter data on the form and it becomesclumsy and difficult to navigate when large numbers of entries must beorganized and presented in such a fashion.

Accordingly, considerable effort has been directed to the development ofimproved systems for recording data especially in environments whereconsiderable amounts of detailed data about a wide variety of subjectsmust be recorded and where the data must be recorded in some detail. Onesuch instance is in medical emergency rooms where doctors are requiredto record data very quickly in order to provide a record for use by thehospital staff and to record their findings, proposed treatment, and thelike with a minimum of effort Similar situations exist in a number ofother areas, but the requirements are particularly acute in hospitalemergency room situations.

Previously, manual data entry systems have been used along withrelatively simplistic forms such as shown in FIG. 1 on computers.

These systems have not been adequate to meet the requirements fordetailed data recording.

Accordingly, an improved method has been sought which permits reportingof detailed amounts of data by yes/no entries by a physician or otherrecorder of information very efficiently.

BRIEF SUMMARY

According to the present invention, such data is effectively enteredquickly and efficiently to produce at least one of a retrievable database and a language text report of the entered data, by a system forentering data by yes/no entries and producing at least one of aretrievable data base and a language text report of the entered data.The system comprises: a workstation comprising a computer, including ascreen capable of displaying a template form capable of receivingentries of yes/no data, capable of accessing a computer and programmedto permit access by an authorized user; a plurality of templates, eachof the templates showing a plurality of relevant inquiries and capableof accepting data entry as yes/no entries by a user, said templatesbeing accessible on the workstation or on a computer accessible by theworkstation; a system access display programmed on the workstation oraccessible by the workstation and providing the capability for a user toaccess a selected database or a selected template; a plurality ofmodifiers related to and associated with designated inquiries on atleast a portion of the templates showing more detailed inquiries relatedto the inquiries on the templates for the entry of additional data; aretrievable database accessible by or on the workstation for storing andretrieving entered data from at least one of the templates andmodifiers; and, a language program accessible by the workstation andcapable of producing a language text report of the entered data.

The present invention further comprises a method for distributing copiesof medical records the method comprising: entering medical records intoa medical records database; entering a plurality of distribution optionsinto a distribution database;

Selecting a distribution option from the distribution database;distributing medical records according to the selected distributionoption; and, retaining in a database a record of the distribution of themedical records for retrieval as required.

The present invention further comprises a system for distributing copiesof medical records, the system comprising: a database containing themedical records; a computer programmed to access die database and todistribute the medical records according to at least one selecteddistribution option via at least one communication means; and, adatabase programmed to retain a record of the medical records sent andthe address to which the medical records were sent for retrieval uponrequest.

The present invention further comprises a method for generating easilyreadable English or other language text from simple sentences with eachof the sentences reporting a single data entry and optionally containingmodifiers of the data entry. The method comprises a method forgenerating easily readable English text from simple sentences, each ofthe sentences reporting a single data entry and optionally containingmodifiers of one or more of the data entries comprising: selecting thewords or phrases which correspond to the reported data entries;selecting which words or phrases can be combined into a single sentenceand selecting the order of the selected words or phrases; limiting thenumber of words or phrases which can be combined in a single sentence;

arranging the words or phrases so that modifiers modify only thedesignated word or phrase; and, supplying the punctuation andconjuctives to create the English text.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a prior art computer display screen for yes/no data entry;

FIG. 2 illustrates a screen display demonstrating the use of the presentinvention on a computer equipped to run the system of the presentinvention on a Microsoft Windows™ software program on a MicrosoftWindows™ capable computer; according to one embodiment of the invention;

FIG. 3 illustrates a screen display demonstrating the use of the presentinvention on a computer equipped to run the system of the presentinvention on a Microsoft Windows™ software program on a MicrosoftWindows™ capable computer; according to one embodiment of the invention;

FIG. 4 illustrates a screen display demonstrating the use of the presentinvention on a computer equipped to run the system of the presentinvention on a Microsoft Windows™ software program on a MicrosoftWindows™ capable computer; according to one embodiment of the invention;

FIG. 5 illustrates a screen display demonstrating the use of the presentinvention on a computer equipped to run the system of the presentinvention on a Microsoft Windows^(TM) software program on a MicrosoftWindows^(TM) capable computer; according to one embodiment of theinvention;

FIG. 6 illustrates a screen display demonstrating the use of the presentinvention on a computer equipped to run the system of the presentinvention on a Microsoft Windows™ software program on a MicrosoftWindows™ capable computer; according to one embodiment of the invention;

FIG. 7 illustrates a screen display demonstrating the use of the presentinvention on a computer equipped to run the system of the presentinvention on a Microsoft Windows™ software program on a MicrosoftWindows™ capable computer; according to one embodiment of the invention;

FIG. 8 illustrates a screen display demonstrating the use of the presentinvention on a computer equipped to run the system of the presentinvention on a Microsoft Windows™ software program on a MicrosoftWindows™ capable computer; according to one embodiment of the invention;

FIGS. 9A and 9B illustrate a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 10 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 11 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 12 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 13 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 14 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 15 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 16 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 17 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 18 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 19 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 20 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 21 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 22 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 23 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 24 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 25 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 26 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 27 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIGS. 28A and 28B illustrate a screen display demonstrating the use ofthe present invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 29 shows a clinical report produced by the system of the presentinvention;

FIG. 30 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 31 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 32 illustrates a screen display demonstrating the use of thepresent invention on a computer equipped to run the system of thepresent invention on a Microsoft Windows™ software program on aMicrosoft Windows™ capable computer; according to one embodiment of theinvention;

FIG. 33 demonstrates a program for producing reports from the system ofthe present invention in accordance with an embodiment of the presentinvention;

FIG. 34 demonstrates a program for producing reports from the system ofthe present invention in accordance with an embodiment of the presentinvention;

FIG. 35 demonstrates a program for producing reports from the system ofthe present invention in accordance with an embodiment of the presentinvention;

FIG. 36 demonstrates a program for producing reports from the system ofthe present invention in accordance with an embodiment of the presentinvention; and

FIG. 33 demonstrates a program for producing reports from the system ofthe present invention in accordance with an embodiment of the presentinvention.

DETAILED DESCRIPTION

In the description of the present invention, a plurality of computerscreens will be shown. It will be understood that the computer screensare illustrative only and that other screens could be used withdifferent formats to perform the same functions. The screens shown inthis Description of Preferred Embodiments illustrate screen displays,which have been found particularly effective for use in the entry ofdata in a medical emergency room application. The system of the presentinvention is equally effective in other situations where data entry isrequired.

In FIG. 2 a typical security display is shown. The user is required toenter his password to provide security for access to the system.

The system comprises a computer programmed to perform the requiredfunctions. The computer can be a handheld terminal, a personal computer,a terminal accessing a suitable computer and the like. The data entrycan be by a computer entry pen, by clicks on a mouse by use of akeyboard, or the like. Particularly, in emergency medical roomenvironments a pen-friendly system may be used. After entry of therequired password, the system displays a screen (system access display)as shown in FIG. 3. This is a main screen or home view of the program.The upper section headed “My Patients” shows all patients presentlyassigned to a physician. The lower section, “Patients Waiting,” shows alist of patients about whom the program has been notified from anothercomputer such as the hospital's admission system but for whom no medicaldata has yet been entered into this program.

The workstation used by the physician or other data recorder can be ahandheld unit, a personal computer a computer workstation or the like.As indicated previously, the data may be entered by pen strokes, byclicking a mouse, typing on a keyboard or the like. The workstation isalso programmed to access a hospital or other mainframe computers toacquire data about the patients presently assigned to the physician.Software and programming for the exchange of such information betweencomputers is well known to those skilled in the art.

In FIG. 4, a patient named “Jack” has been selected for treatment. Thispatient has been identified by the pointer and in FIG. 5 has been movedto the “My Patients” section which is accomplished by dragging thepatient's name from the lower to the upper section of the screen. Thepatient is now assigned to the attending physician. The physician mayalso move the new complaint from the lower to the upper section of thescreen. This entry allows the physician to begin entering data for thepatient who may have not been previously admitted by the hospitaladmitting system.

In FIG. 6, the physician has identified a patient room for the patient.The physician can also enter the patient's vital statistics, such asname, sex, age, chief complaint, arrival time, etc., using the sametechnique as for the room number. The system usually discourageschanging information of this type, which may have been received from thehospital directly. In addition to the use of pen/tablet devices, otherdevices may be used which can provide handwriting recognition to supportthe data entry process. Voice recognition may also be used for thispurpose.

With the room number assigned, the physician has a clear view of his/hercurrent patients as shown in FIG. 6. The highlighted patient isidentified as the selected patient who will be the subject of theactions described below. It will be understood that the physician couldalternatively select a different patient by selecting, tapping orclicking on a different patient Please note in FIG. 6 at the left under“Clinical” four entries are possible: “History”; “Exam”; “Course”; and“D×DI.” These entries refer to different sections of the system andprovide templates, which may be used to enter different types of data.

The “History” section allows the entry of data pertaining to the historyof the present illness, a review of systems, a past history (includingsocial history) and may include the first part of a physical exam, ifdesired. It is into this section that the physician will usually firstbegin entering data.

The “Exam” should allow the entry of the majority of informationregarding a physical examination.

The “Course” section provides for entry of data regarding variousprocedures and the progress of the case during the course of thepatient's visit to the emergency room or hospital departments. Thephysician can return to this section several times during the course ofa patient's visit

The “D×DI” provides for the entry of clinical impression, prescriptions,work excuse, discharge instructions and the like. This section isgenerally used by the physician to complete a case.

As indicated previously, these sections appear at the left side of themain screen and can be selected by computer entry pen strokes, byclicking a mouse, typing on a keyboard or the like. Various otheroperations can be selected for various other software functions from thesystem access display.

If the physician taps or clicks one of the sections on a selectedpatient and the patient currently has no current medical record, theprogram prompts the physician to select the desired template bydisplaying a template selector as shown in FIG. 7.

Each template provides for entry by the physician of the clinicallyrelevant data for the associated chief complaint. Each template alsoprovides for the entry of data less clinically relevant to the chiefcomplaint For example, the template for a motor vehicle accident shouldprovide for entry of crucial information about head injuries, which areof a particular concern in such cases. It also should provide for theentry of somewhat detailed information about broken bones, however, itneed only provide rudimentary entering capabilities for injuries such asinsect bites. For this reason, the program need only allow a singletemplate, which may be selected for a given patient visit.

As shown in FIG. 8, in the described template, “Abdominal Pain” has beenselected by positioning the arrow on the desired template. Selecting thedesired template results in the display of a chart as shown in FIG. 9for abdominal pain. This illustration shows the “History” section forabdominal pain. The History section under “clinical” is colored asshown. The physician can easily view the other sections by selecting the“Exam”, “Course” or “D×DI” buttons. Tapping or clicking the home buttonbeneath the patient's name brings back the original view of the patientson the main screen.

In FIG. 10, a selection is indicated by the arrow that abdominal pain isor will be the chief complaint The present system does not useconventional check boxes or other data entry methods. The current systemhas been developed to be readily grasped and used by physicians who arenot expert computer users but still appeal to highly computer literateindividuals.

It is important that the organization of the data entry points presentsitself to the user in a manner that provides effortless orientation forboth new and experienced users.

FIG. 10 shows a mouse cursor positioned over a finding of abdominal painas the chief complaint in the history of present illness portion of the“History” section of a template for abdominal pain.

Please note the small circles to the left of “HPI”, “ROS” and “Past Hx.”These indicate the availability of sub-templates for these headings.Sub-templates will be discussed in greater detail below.

In FIG. 10, tapping or clicking the heading “abdominal pain” results ina circle around the term “abdominal pain” indicating a positive finding.As shown in FIG. 11, an indication of abdominal pain is shown. In FIG.12 a further indication has been made that nausea is present Thisindication is made in the same way by selecting “Nausea.” In FIG. 13,the information has been added that there has been loss of appetite.This is done by tapping or clicking on the “Loss of Appetite” term.

In FIG. 14, it has been indicated that there is no vomiting. Using thesecondary mouse button (normally the right button), or tapping with atablet pen near the right of the word creates a backslash instead of acircle. This indicates a negative finding, in this case, no vomiting.

In FIG. 15, a further indication has been made in the same way thatthere is no diarrhea.

Although the circles and backslashes provide an ideal visualrepresentation of findings, it is necessary to present this informationin a text format which can be stored in hospital archives, transmitted,printed and viewed without the requirement for a graphical presentation.Clicking the report entry as shown on the main screen beneath theviewing section, causes the program to generate a textual (prose)representation of the remarks entered by the physician. In FIG. 16, theclinical report of the information entered previously is shown intextual form.

In FIG. 17, the cursor has been placed on the line at “Cough” andselecting the entry at the line may permit the entry of more detailedinformation. The system provides methods for going into greater detail.The mouse pointer shown over the line in FIG. 17 extending to the rightof “Cough” permits clicking on the line which brings up additionaldetails (modifier) one might wish to describe for that finding as shownin FIG. 18.

As shown in FIG. 19, the recorder has indicated on the modifier that thecough is severe, that it has been productive, thick, green andblood-tinged but with no “frank blood”. These details are entered bycircles and backslashes as described previously.

The clinical report based upon this additional information is shown inFIG. 20.

In FIG. 21, it is indicated that by clicking on the “X” at the upperright the modifier can be deleted. It can also be deleted by clicking ortapping another finding somewhere else on the screen.

After the modifier has been deleted, (FIG. 22) the additionalinformation remains on the line following “Cough” indicating that moreinformation is available.

In FIG. 23-26, a set of template sheets is shown illustrating thedifferences between the “History”, “Exam”, “Course”, and “D×DI” sheets.All of these templates are for a motor vehicle accident, with FIG. 23showing a sheet for “History,” FIG. 24 shows the “Exam” sheet, FIG. 25shows a sheet for “Course,” and FIG. 26 shows a sheet for “D×DI.” Thesesheets as discussed previously relate to different aspects of apatient's treatment While not discussed above, the templates may alsoinclude sub-templates, which permit the entry of additional data aboutany particular heading shown on the template. Various findings in thesub-templates may also include modifiers, which include additionalentries, which may be made with respect to any of the conditionsreferred to on the sub-template.

In FIG. 27, a sub-template is shown. The sub-template is headed “OtherHistory.” This sub-template is available by clicking on the circle infront of the heading “HPI.” This sub-template enables the entry ofadditional information.

As further shown in FIG. 27, a modifier is available and is shown on thesub template in connection with vomiting. Additional information can beshown by marking entries on the modifier as discussed previously.

As shown, these screen displays demonstrate one embodiment of the systemof the present invention for use in a hospital emergency room. Asindicated, this system can be used for a wide variety of data entryapplications. The system registers a positive finding when a tablet pentouches the left side of an unmarked finding. It should be appreciatedthat any number of systems can be used for data entry. Typically in thecurrent system, a negative finding is registered when the user rightclicks or taps the right side of an unmarked finding. The selection of apreviously marked finding clears or reverses the indicated mark therebyproviding the user with a intuitive mechanism for correcting data entryerrors. Those discussed herein are preferred and have been found to beeffective. They should be considered to be illustrative disclosures ofmethods for entering, reporting and distributing the data.

On tablet-based systems, in addition to recognizing the left and righttaps as requests to enter positive and negative findings respectively,it is desirable for the software to recognize pen movements, circling orbackslashing the word and to translate those into positive and negativefindings. The effect observed by the user is that drawing a circle or abackslash around the typesetting enters the positive or negativefindings. The circles and backslashes can be used to illustrate multiplepositive or negative findings.

The forms are desirably laid out to permit the user to readily enterdata with a minimum of effort Accordingly, the forms should provide theability to enter most data by yes/no entries.

In the present system, most of the templates are desirably designed sothat a simple yes/no answer can be used to indicate the data. Forexample, “The patient has chest pain. ” or “The patient does not havechest pain.” Sometimes it is desirable to provide more information. Ifspecified by the form layout, the software must present a visual cuethat entry of detailed findings is possible. One such visual cue is todraw a horizontal line to the right of the finding, as illustrated onall findings in the ROS section in FIG. 9. In such cases, the user canclick or tap the horizontal line in order to request an opportunity toenter more detailed information about the finding in question. Thesoftware responds by presenting one or more of the following data entryoptions, as specified by the layout: (1) simple text, (2) sentencebuilders, and (3) modifiers. The user may enter data as desired, andthen dismiss the data entry option(s), generally by either (a) clickingor tapping a “close” icon associated with the data entry option or (b)activating data entry into an unrelated finding by clicking or tappingit.

As illustrated previously, the software in the system should present avisual clue that detailed information has been entered for a givenfinding. For instance, as shown in FIG. 22 after the word “Cough”additional information is shown. This provides an indication that moreinformation is available with respect to this finding.

It is not considered necessary that the visual clue for detailedfindings actually shows the detailed findings completely. It issufficient that the indication is made that detailed findings wererecorded.

In addition for providing for the entry of data as a detailed finding,the software should also enter simple text (simple sentences) thatstands on its own. This should be enterable using conventional methodssuch as the use of a backspace, left and right arrow and similarnavigation keys, word wrap, use of scroll bars and the like to accessthe entire text and voice or handwriting recognition should be accepted.The entered text should then be displayed over the lines near theentries or at other places as indicated. If the entered text is toolengthy to appear within the available space a visual clue should beindicated.

The entry of detailed findings can be augmented with sentence buildersto accelerate entry of simple text as shown in FIG. 27. The upperportion of the pull-down shown permits selection of for instance “for”,“several” and “days”. This would result in a report that, “The patienthas vomiting (for several days)*’. Additional information can be shownby typing in the data entry space provided. Information may also beshown by selecting the findings on the modifier (pull-down). Sentencebuilders are another data entry option, which may be invoked in the formdesign.

This system may also be used with a medical records distribution system.Typically such medical record distribution systems comprise a computerprogrammed to access a database of such medical records and a databaseincluding distribution options. These options may include distributionof the information, for instance, to a second or additional physicians,to insurance companies, or other payers and the like. Normally, thedistribution option is selectable for each medical record, which is tobe distributed. The selected option may be implemented by electronicallydistributing the records via e-mail or other similar communicationsystems or the distribution system may produce a hard copy letter or thelike, of the medical records to be distributed with suitable addressesfor mailing to the desired recipients. Desirably, the system is also incommunication with a database, which maintains a record of thedistributed medical records and of the recipients of those medicalrecords.

In FIG. 28, an exam template for abdominal pain is shown. On thistemplate, various findings have been indicated positively by circles.

A clinical report is shown in FIG. 29 reporting the data entered in FIG.28. In FIG. 28, by clicking on FEM GENITALIA a sub-template headed“Pelvic Exam” is available as shown in FIG. 30. Certain findings havebeen indicated on this sub-template as shown by circles.

In FIG. 31, a clinical report including this information, in addition tothat available previously from FIG. 28, is shown.

By clicking on the line following the entry for “Time” under “Progress”in FIG. 32, a “Progress and Procedures Note” is available for indicatingchanges in the patient's condition, medicines administered and the like.In the note shown, the patient has been subjected to observation, testshave been returned, an analgesic has been administered and a narcotichas been administered. As a result of this treatment, the patient'scondition is much better and the exam findings have improved. It will benoted that under the “Note” are notes from previous entries on previous“Notes.” This allows the physician to enter patient treatmentinformation sequentially. If it is desired to enter the time, it can beentered, but is not necessary. It is generally considered more importantto enter the sequence of treatment rather than the exact times that thetreatments are performed. In FIG. 33 the entered data is shown for thenotes cumulatively in the “Progress” section.

In FIG. 34, the clinical report is provided. The “PAST HISTORY” includesdata entered previously on a History template, the “PHYSICAL EXAM”information includes information previously entered on an Exam templateand the PROGRESS AND PROCEDURES″ notes are entered on the Progress andProcedures section.

The reports of the recorded data are typically made by programming,which produces the reports as a plurality of simple sentences having asingle object or a single clause.

As shown in FIG. 35, two phrases are shown in a diagram for condensingthese phrases. The phrases are “The chest pain was described as dull.”and “The chest pain was not relieved by nitroglycerin.” These twophrases have been drawn as a diagram which shows the essential contentof an internal data structure created by the computer program uponprocessing those phrases. The preferred form of the internal datastructure is generally a data tree, although other suitable structuresknown to those skilled in the art could be used.

The program builds the tree by processing each phrase in turn. Eachsuccessive word in each phrase is added to the tree so that thecollective content of all the phrases is contained in the tree assuggested in FIG. 35.

The program also maintains a tally of the number of positive andnegative phrases found for each word in the tree. As shown in FIG. 35,the first four words of all phrases in this example are “the”, “chest”,“pain” and “was, and each of these is associated with one positivephrase (“+1” in the diagram) and one negative phrase (“−1” in thediagram). As described below, the program may permit the authorflexibility in the manner in which the program generates text from thetree thus produced. The information required for the program toaccommodate the author's wishes, such as desired ordering of phrases oruse of conjunctive words as described below, can be stored in the nodesof the tree. The particular information to be stored in each nodedepends upon the options desired.

To generate sentences from the tree, the program traverses the nodes ofthe tree, nominally in order of their appearance in the tree, butaltered as necessary to reflect any desired ordering imperatives.Successive nodes such as “the”, “chest”, “pain” and “was” in FIG. 35constitute a common pretext for any sentence(s) generated from the leastsignificant, or rightmost, node, in this case “was”. The traversalprocess at a node which branches into two or more subtrees, such as“was” in FIG. 35, produces the necessary sentence(s) as the commonpretext, in this case “The chest pain was” followed by a list of phrasesgenerated from each subtree, such that any positive phrases areextracted from the subtrees and combined in an “a, b, c and d” pattern,and similarly any negative phrases are extracted from the subtrees andcombined in an “a, b, c or d” pattern, and such that if both negativeand positive phrases were found, the positive phrases come first and arefollowed by the conjunctive word “but” and then the extracted negativephrases.

Accordingly, the sentence resulting from the combination of the phrasesin FIG. 35 would say, “The chest pain was described as dull but notrelieved by nitroglycerin.” In the construction of the sentences, “but”is used to indicate a negative and in the event that more than onenegative clause is used, the clauses may be separated by “or's. “In therecitation of a plurality of positive phrases, the phrases are separatedby “and's.” Arbitrarily, it has been determined the sentences containingmore than five clauses are unduly complex and the combination of singlesentences is preferably limited to five clauses.

In FIG. 36, a more complicated diagram is shown. The eight sentencesshown beneath the diagram are to be combined into more complex and morereadable sentences. It will be noted that “the” appears in six positivestatements and two negative statements. This assignment of valuescontinues through the word “was.” “Was” is followed by the word“described” twice, indicated by the numeral “+2” beside the word“described.” The word “as” similarly appears twice and the words “dull”and “squeezing” each appear once. A similar assignment of numbers isfound with the negative statements which are shown directly beneath“was” with a “−2” being assigned to “not” and “−1's” being assigned tothe words following the “not.” Similarly, the word “similar” occurs onceand this is shown by the “+1's”. The word “associated” follows the word“was” three times and this is indicated by the numerals “+3” with eachof the individual phrases following from the word “associated” beingnumbered with “+1's”.

The net result of the combination is that it is not possible to combineall of the clauses without exceeding the limitation of five clauses persentence.

The traversal process described above works well even when a treecontains complex nested subtrees such as that shown in FIG. 36. In sucha case, the subtrees are traversed as before and the resulting textstill reads well. New sentences can be started at any given node,whenever necessary either to avoid exceeding the maximum number ofclauses, or to comply with the author's requirements. Accordingly, whilea number of combinations might be possible, the most likely combinationis the following. “The chest pain was described as dull and squeezingand similar to previous episodes but not relieved by nitroglycerin orassociated with vomiting. The chest pain was associated with nausea,shortness of breath and dizziness.”

Similar applications can be made to any group of sentences produced bythe program, which produces simple sentences having a single object orclause. Clearly, the assignment of a limit of five clauses per sentenceis arbitrary and fewer or more clauses could be used if desired. Whilethis embodiment is relatively specific, it should be understood that alarge number of programs using this type of approach could be used toconvert the simple sentences to longer sentences to more accurately andreadably convey the data.

In addition to the limitations discussed above, the program is designedto permit the author flexibility in the expression. For instance, in thecombination of the two sentences referred to in FIG. 35, the resultingsentence could also by produced by an option which causes the sentenceto read “The chest pain was described as dull, but was not relieved bynitroglycerin.” Clearly the use of the second occurrence of the word“was” is optional and may be preferred by some users. Further, theprogram offers the capability to select a conjunction of choice. Forinstance, “and”, “of” or “nor” could be selected. The appropriateconjunctive is selectable by the user. The program will provideconjunctives as indicated previously with “and” separating positiveclauses and “or” separating negative clauses with a “but” separating thepositive and negative clauses, unless modified.

The program also permits the user to alter the order of the clauses byassigning selected number values to the clauses to designate the orderin which they appear in the sentence. The simple sentences may begrouped as desired in the combined sentence by designating the clausesin the order in which they are to appear in the combined sentence byassigning numbers to each of the clauses. As a further feature, selectedwords may be left in the combined sentence which would otherwise havebeen deleted by bracketing or indicating the words which are to beretained which would normally have been deleted.

It may be desirable in some instances to eliminate redundancy and inother areas to create deliberate redundancy. In general, considerableflexibility is left to the user of the program to generate the combinedsentence to most accurately reflect the combined meaning of the simplesentences.

Many variations and modifications are possible within the scope of thistechnique. In general, special punctuation may be used as an instructionto the program to add words, delete words, reorganize words and thelike. Further, the desired punctuation to arrange the clauses in adesired order may be specified on the template or sub-template ormodifier sheets so that when the simple sentences are produced, they areproduced with the desired indicators to cause the combined sentence tobe produced in a desired form. Other variations may also appeardesirable to those skilled in the art based upon the foregoingdescription.

Further with reference to FIG. 34, please note that the clinical reportis organized to recite the name of the template from which the data isobtained. In the case of the physical exam, it is laid out to refer tothe section of the physical exam from which the data is entered, forinstance, the data is entered for :“Eyes”, “ENT”, “Neck”, “Abdomen”,“GU”, “Skin”, and “Neuro.” In the Progress and Procedures section, thedata reported is all reported under the ED Course, which is the sectionin which the evaluation and reassessment data is reported.

In FIG. 37, a plurality of sentences is shown with an indication aheadof each clause indicating that there is to be no clause reduction. Thisembodiment may be desirable in many instances with a prior medicalhistory where it is desired that the phrases be made available to thephysician without modification.

In further modifications, for instance with the vomiting modifiersdiscussed above, it may be indicated that severe vomiting is present,that the vomit is blood tinged and contains frank blood. This sentencemay be varied by suitable punctuation to read

“He has had severe blood tinged vomiting containing frank blood.” oralternatively could be punctuated to read “He has had severe bloodtinged vomiting. The vomitus contains frank blood.” The development ofpunctuation to position the clauses relative to each other and thepunctuation available to remove redundancy and to properly placeadjectives and the like permits tremendous flexibility in theconstruction of the complex sentences.

In summary, the present system is effective to record medical data orother data which is conveniently entered by a professional or otherobserver by entering yes/no entries into a system to enter the dataeffectively, transmit it to a desired records system or otherwise makeit available for use with respect to the individual, reported by therecorder or by another party.

While the description above has illustrated the invention specificallywith respect to a medical emergency room data entry system, it should beunderstood that this system is much more widely usable in otherapplications although the use of the system is particularly effectivefor the entry of data in a medical emergency room situation.

Having thus described the invention by reference to certain of itspreferred embodiments, it is noted that the embodiments described areillustrative rather than limiting in nature and that many variations andmodifications are possible within the scope of the present invention.Many such variations and modifications may be considered to be obviousor desirable to those skilled in the art based upon the foregoingdescription of preferred embodiments.

1-26. (canceled)
 27. A computer program product including acomputer-readable medium having instructions stored thereon, which whenexecuted the computing device is configured to: present a plurality ofscreen presentations, wherein the plurality of screen presentationsincludes multiple screens having selectable data items, wherein at leastone selectable data item in the selectable data items includes a textualrepresentation of the selectable data item, the textual representationbeing the actual textual label representing the selectable data item;and receive yes/no data entries for the selectable data items, wherein afirst type of yes/no data entry indicates a positive finding, and asecond type of yes/no data entry indicates a negative finding, wherein aselection of a positive finding of the at least one selectable data itemand a selection of the negative finding of the at least one selectabledata item require an affirmative selection from a user, wherein theselection of the positive finding of the at least one selectable dataitem is performed on the textual representation of the at least oneselectable data item, and the selection of the negative finding of theat least one selectable data item is performed on the textualrepresentation of the at least one selectable data item, wherein theselection of the positive finding of the at least one selectable dataitem causes a first visual indicator to be displayed corresponding tothe at least one selectable data item, and the selection of the negativefinding of the at least one selectable data item causes a second visualindicator to be displayed corresponding to the at least one selectabledata item, the first visual indicator being different than the secondvisual indicator.
 28. The computer program product of claim 1 furtherconfigured to: receive a selection corresponding to a template; andpresent a plurality of screen presentations, wherein the plurality ofscreen presentations includes multiple screens having selectable dataitems which are pre-identified to be of particular concern to theselected template.
 29. The computer program product of claim 27 whereinat least one selectable data item includes a word representing aclinical data item.
 30. The computer program product of claim 27 furtherconfigured to capture additional medical information regarding at leastone selectable data item.
 31. The computer program product of claim 30further configured to display a visual cue signaling that additionalinformation regarding at least one selectable data item may be entered.32. The computer program product of claim 31 further configured todisplay an additional menu when the visual cue is selected, theadditional menu including additional selectable data items relating tothe selected data item.
 33. The computer program product of claim 32further configured to receive yes/no data entries for the additionalselectable data items of the additional menu, wherein the selection of apositive finding of the additional selectable data items is performed onthe textual representation of the at least additional selectable dataitem, and the selection of the negative finding of the at least oneadditional selectable data item is performed on the textualrepresentation of the at least one additional selectable data item. 34.The computer program product of claim 27 further configured to display apre-identified graphic on at least one screen presentation of theplurality of screen presentations, wherein the pre-identified graphicshows only areas of concern for a selected template of screenpresentations.
 35. The computer program product of claim 34 wherein thepre-identified graphic comprises selectable data item labels overlaid onthe graphic, wherein the selection of a positive finding of theselectable data item labels overlaid on the graphic is performed on thetextual representation of a at least additional selectable data item,and the selection of the negative finding of the selectable data itemlabels overlaid on the graphic is performed on the textualrepresentation of the at least one additional selectable data item. 36.The computer program product of claim 27 further configured to receive aprimary user input of the at least one selectable data item to indicatethe selection of the positive finding of the at least one selectabledata item and a secondary user input of the at least one selectable dataitem to indicate the selection of the negative finding of the at leastone selectable data item.
 37. The computer program product of claim 36wherein the primary user input is a left mouse click on the data itemand the secondary user input is a right mouse click on the data item.38. The computer program product of claim 36 wherein the primary userinput is indicated by tapping one side of the clinical item and thesecondary user input is indicated by tapping another side of the dataitem.
 39. The computer program product of claim 36 wherein the displayedfirst visual indicator is a circle encircling the selected clinical itemand the displayed second visual indicator is a strike-through of theselected data item.
 40. The computer program product of claim 36 furtherconfigured to compile a textual prose representation correlating datafrom selected data items as each item is selected.
 41. A methodcomprising: presenting to a user of a computing device at least onescreen presentation, wherein the at least one screen presentationincludes a plurality of selectable data items, wherein at least oneselectable data item of the plurality of selectable data items includesa textual representation of the selectable data item, the textualrepresentation being the actual textual label representing theselectable data item; and receiving yes/no data entries for theselectable data items at the computing device, wherein a first type ofyes/no data entry indicates a positive finding, and a second type ofyes/no data entry indicates a negative finding, wherein a selection of apositive finding of the at least one selectable data item and aselection of a negative finding of the at least one selectable data itemrequire an affirmative selection from the user, wherein the selection ofthe positive finding of the at least one selectable data item isperformed on the textual representation of the at least one selectabledata item, and the selection of the negative finding of the of the atleast one selectable data item is performed on the textualrepresentation of the of the at least one selectable data item, whereinthe selection of the positive finding of the at least one selectabledata item causes a first visual indicator to be displayed correspondingto the textual representation of the at least one selectable data item,and the selection of the negative finding of the at least one selectabledata item causes a second visual indicator to be displayed correspondingto the textual representation of the at least one selectable data item,the first visual indicator being different than the second visualindicator.
 42. The method of claim 41, further comprising: displaying avisual cue indicating that additional information regarding at least oneselectable data item may be entered; and receiving additional medicalinformation regarding at least one selectable data item.
 43. The methodof claim 42 further comprising: displaying an additional menu when thevisual cue is selected, the additional menu including additionalselectable data items relating to the selected data item; and receivingyes/no data entries for the selectable data items of the additionalmenu, wherein the selection of a positive finding of the additionalselectable data items is performed on the textual representation of atleast additional selectable data item, and the selection of the negativefinding of the at least one additional selectable data item is performedon the textual representation of the at least one additional selectabledata item.
 44. The method of claim 41 further comprising: presenting toa user a pre-identified graphic on at least one screen presentation ofthe plurality of screen presentations, wherein the pre-identifiedgraphic shows only areas of concern for a selected template of screenpresentations.
 45. The method of claim 44 wherein the pre-identifiedgraphic comprises selectable data item labels overlaid on the graphic,wherein the selection of a positive finding of the selectable data itemlabels overlaid on the graphic is performed on the textualrepresentation of at least additional selectable data item, and theselection of the negative finding of the selectable data item labelsoverlaid on the graphic is performed on the textual representation ofthe at least one additional selectable data item.
 46. The method ofclaim 41 further comprising receiving a primary user input for the atleast one selectable data items to indicate the selection of thepositive finding of the at least one selectable data item and asecondary user input for the at least one data item to indicate theselection of the negative finding of the at least one selectable dataitem.
 47. The method of claim 46 wherein the primary user input is aleft mouse click on the data item and the secondary user input is aright mouse click on the data item.
 48. The method of claim 46 whereinthe primary user input is indicated by tapping one side of the data itemand the secondary user input is indicated by tapping another side of thedata item.
 49. The method of claim 46 wherein the displayed first visualindicator is a circle encircling the selected data item and thedisplayed second visual indicator is a strike-through of the selecteddata item.
 50. The method of claim 41 further comprising compiling atextual prose representation correlating data from selected data itemsas each item is selected.
 51. The method of claim 50 wherein the textualprose representation is dynamically generated upon receiving individualselections of data items.